Health inspection·September 20, 2023

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to administer Heparin Sodium Injection Solution 5000 Unit/ml (a medication used to prevent and treat blood clots and other clotting-related conditions) for one (Resident 1) of four sampled residents. Residents Affected - Few This failure resulted in Resident 1 not receiving medications as per physician's orders and placing Resident 1 at high risk for developing a blood clot. Findings: During a review of Resident 1's admission record, printed on 9/20/23, the admission record indicated Resident 1 was originally admitted to the facility on [DATE]. During a review of Resident 1's Physician orders dated 8/23/23, the Physician orders indicated to administer Heparin Sodium (Porcine) Injection Solution 5000 Unit/ml subcutaneously (injected into the tissue between the skin and muscle) every 12 hours (9:00 a.m. and 9:00 p.m.) for DVT (Deep vein thrombosis -a condition in which the blood clots form in veins located deep inside the body, usually in the thigh or lower legs) Prophylaxis. During a concurrent interview and record review on 9/20/23, at 2:15 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 1's Medication administration record (MAR), dated 8/2023 and Progress notes , dated 8/23/23 and 8/24/23 were reviewed. The MAR indicated, on 8/23/23, for the 9 a.m. administration time and for 8/24/23 at 9 .00 p.m., administration time, the MAR was coded 9 . LVN 1 stated that code 9 indicated the medication was not administered. LVN 1 stated the progress notes dated 8/24/23 indicated that the medication Heparin sodium was not available. During a concurrent observation and interview on 9/20/23, at 2:24 p.m. with LVN 1, in the Medication room, the facility's emergency kit was observed. LVN1 stated that Heparin Sodium Injection was available in the facility's Emergency Kit (Ekit) and should have been given to the resident as per Physician orders if unavailable in the medication cart. LVN 1 stated it was important to provide Heparin Sodium to Resident 1 to prevent blood clots. During an interview on 9/20/23, at 2:52 p.m. with LVN 2, LVN 2 stated on 8/24/23 she was not able to find the medication in the medication cart and called pharmacy to follow up but did not check the Ekit at the facility and did not administer Heparin sodium from the Ekit. During an interview on 9/20/23, at 2:30 p.m. with Director of Nursing (DON), the DON stated it was not acceptable that the Licensed Nurses did not administer Heparin Sodium to Resident 1 when it was Page 1 of 2 555341 555341 09/20/2023 Canyon Creek Post-Acute 22103 Redwood Road Castro Valley, CA 94546

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few available in the Ekit. DON also stated Heparin Sodium should be given continuously as per doctor's orders and missing the dose placed Resident 1 at a high risk for developing a blood clot. During a review of the facility's policy and procedure (P&P), revised on 04/2019, titled, Administering Medications , was reviewed. The P&P indicated, Medications are administered in a safe and timely manner, and as prescribed . 555341 Page 2 of 2